Client Intake
Facial Treatments
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Do you use any acne or any other medication? If yes, which medication?
*
Does your job require that you work outdoors?
*
Yes
No
What would you like to achieve from your treatment today? (What are your skin concerns)
*
Have you ever had a facial treatment before?
*
No
Yes
Do you have any special skin problems or concerns pertaining to your face?
*
If yes, when?
Which of the following best describes your skin type? (Please choose only 1)
*
I - Creamy complexion , Always burns easily, never tans
II Light Complexion- Always burns, tans slightly
III Light/Matte Complexion- Burns moderately, tans gradually
IV Matte Complexion- Seldom burns, always tans well
V Brown Complexion- Rarely burns, deep tan
VI Deep Brown Complexion- Never burns, deeply pigmented
Have you ever had chemical peels, laser, or microdermabrasion?
*
Yes
No
If yes, were any of these services in the last month?
Yes
No
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products?
*
Yes
No
If yes, what products do you use and how long have you been using them?
What skin care products are you currently using?
*
Have you recently used any self-tanning lotions, creams or treatments?
*
Yes
No
If yes, please specify
Have you used any of the following hair removal methods in the past six weeks? Check all that apply.
*
Shaving
Waxing
Electrolysis
Tweezing
Threading
Depilatories ( Hair removal cream)
Have you ever had an allergic reaction to any of the following? Check all that apply.
*
Cosmetics
Medicine
Sunscreen
Iodine
AHAs (Alpha Hydroxy Acid)
Fragrance
Latex
Other
Have you ever had Botox, Restylane, or collagen injections? If yes, please specify.
*
(Female clients) Are you currently pregnant or trying to become?
Yes
No
(Make clients) What is your current shaving system?
Wet shave
Electric
Do you experience irritation from shaving?
Yes Redness/Sensitivity/Ingrown Hairs
No
I certified the preceding medical, personal, and skin history treatments are true and correct. I release my esthetician and KT Esthetics and Beauty from any and all liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation and proper application using tools and products that the esthetician is trained to use. I am aware that it is my responsibility to inform the esthetician of my current medical and health conditions, and to update this information at subsequent visits. A current history is essential for the provider to execute appropriate treatment procedures, I have signed the consent form for this procedure. I have the opportunity to ask questions prior to the treatment.
Please initial and date to show that you have read and agree to all policies
Signature
Submit
Submit
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